|
ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION [132613]
|
Facility
|
IP
|
$20,861.00
|
|
|
Service Code
|
HCPCS J9022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17,731.85 |
| Max. Negotiated Rate |
$20,235.17 |
| Rate for Payer: Cash Price |
$12,516.60
|
| Rate for Payer: Health Management Network Commercial |
$17,731.85
|
| Rate for Payer: MDX Hawaii PPO |
$20,235.17
|
|
|
ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION [132613]
|
Facility
|
OP
|
$20,861.00
|
|
|
Service Code
|
HCPCS J9022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$20,235.17 |
| Rate for Payer: AlohaCare Medicaid |
$94.00
|
| Rate for Payer: AlohaCare Medicare |
$94.00
|
| Rate for Payer: Cash Price |
$12,516.60
|
| Rate for Payer: Cash Price |
$12,516.60
|
| Rate for Payer: Devoted Health Medicare |
$103.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$91.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$117.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$91.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19,817.95
|
| Rate for Payer: Health Management Network Commercial |
$17,731.85
|
| Rate for Payer: Humana Medicare |
$94.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,142.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,639.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$94.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,235.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12,516.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.00
|
| Rate for Payer: University Health Alliance Commercial |
$15,205.58
|
|
|
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [166705]
|
Facility
|
OP
|
$13,630.00
|
|
|
Service Code
|
HCPCS J9022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$13,221.10 |
| Rate for Payer: AlohaCare Medicaid |
$94.00
|
| Rate for Payer: AlohaCare Medicare |
$94.00
|
| Rate for Payer: Cash Price |
$8,178.00
|
| Rate for Payer: Cash Price |
$8,178.00
|
| Rate for Payer: Devoted Health Medicare |
$103.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$91.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$117.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$91.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,948.50
|
| Rate for Payer: Health Management Network Commercial |
$11,585.50
|
| Rate for Payer: Humana Medicare |
$94.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,586.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,951.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$94.00
|
| Rate for Payer: MDX Hawaii PPO |
$13,221.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,178.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.00
|
| Rate for Payer: University Health Alliance Commercial |
$9,934.91
|
|
|
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION [166705]
|
Facility
|
IP
|
$13,630.00
|
|
|
Service Code
|
HCPCS J9022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,585.50 |
| Max. Negotiated Rate |
$13,221.10 |
| Rate for Payer: Cash Price |
$8,178.00
|
| Rate for Payer: Health Management Network Commercial |
$11,585.50
|
| Rate for Payer: MDX Hawaii PPO |
$13,221.10
|
|
|
ATHEROSCLEROSIS WITH MCC
|
Facility
|
IP
|
$20,641.35
|
|
|
Service Code
|
MSDRG 302
|
| Min. Negotiated Rate |
$13,610.41 |
| Max. Negotiated Rate |
$20,641.35 |
| Rate for Payer: AlohaCare Medicare |
$13,610.41
|
| Rate for Payer: Devoted Health Medicare |
$14,971.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,535.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13,610.41
|
| Rate for Payer: Humana Medicare |
$13,610.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,641.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$13,610.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$13,610.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$13,610.41
|
|
|
ATHEROSCLEROSIS WITHOUT MCC
|
Facility
|
IP
|
$14,414.00
|
|
|
Service Code
|
MSDRG 303
|
| Min. Negotiated Rate |
$7,657.15 |
| Max. Negotiated Rate |
$14,414.00 |
| Rate for Payer: AlohaCare Medicare |
$7,657.15
|
| Rate for Payer: Devoted Health Medicare |
$8,422.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,414.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,657.15
|
| Rate for Payer: Humana Medicare |
$7,657.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,612.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,657.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,657.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,657.15
|
|
|
ATLAS GOLD NC 8F 18X40X120
|
Facility
|
OP
|
$1,488.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$758.88 |
| Max. Negotiated Rate |
$1,443.36 |
| Rate for Payer: Cash Price |
$892.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,413.60
|
| Rate for Payer: Health Management Network Commercial |
$1,264.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$937.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$758.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,443.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,084.60
|
|
|
ATLAS GOLD NC 8F 18X40X120
|
Facility
|
IP
|
$1,488.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,264.80 |
| Max. Negotiated Rate |
$1,443.36 |
| Rate for Payer: Cash Price |
$892.80
|
| Rate for Payer: Health Management Network Commercial |
$1,264.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,443.36
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079021103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 68084059095
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084059025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084059095
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 68084059025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
